Uninterrupted vitamin K antagonists in patients undergoing transcatheter aortic valve implantation: A promising strategy still looking for the right patient.

Up to one‐third of patients undergoing transcatheter aortic valve implantation (TAVI) have also an indication for long‐term anticoagulation. In this kind of patients, a thorough evaluation of bleeding and ischemic risks is important to decide the best peri‐ and postprocedural anticoagulation therapy. Traditionally, oral anticoagulation (OAC) is usually uninterrupted during peri‐procedural period and, for patients who receive Warfarin, a short bridging therapy with low molecular weight heparin (LMWH) is generally administred. However, data for patients undergoing transfemoral TAVI with uninterrupted (U)‐OAC continuation are lacking. So far, some few studies have shown promising results of an U‐OAC strategy, with comparable outcomes between patients with and without OAC interruption. , To note, these registries included nonrandomized patients either on Warfarin or on direct oral anticoagulants (DOAC), with no further evaluations on the possible impact of different OAC therapies on outcomes.

In this issue of CCI, Robert et al. analyzed data from an observational, prospective, monocenter registry, including 88 patients with an indication for long‐term OAC who underwent TAVI between January 2016 and October 2017. The median STS score was 5.1 and the main reason for long‐term OAC was atrial fibrillation (90%). All patients were under vitamin K antagonist (VKA) treatment and received continuing OAC during peri‐procedural period. One‐month outcomes showed low rates of bleeding events and vascular complications, comparable with those previously reported in literature for the same subset of patients.

Furthermore, a higher body max index (BMI) and INR > 2.5 were found as important predictors of adverse outcomes at multivariate analysis.

During the last years, a number of new therapeutic strategies have been adopted to minimize procedural complications. One of them, maybe the (D)OAC therapy continuation during TAVI, possibly reducing peri‐procedural thrombo‐embolic risk. The price to pay for this strategy is 8% of vascular complications and 6% of major bleedings within the first month. To note, these numbers are consistent with those reported in previous studies, , though, in the current analysis, the authors included only patients receiving VKA. In previous randomized trials, DOAC didn't seem to perform better than VKA. Indeed, in the ENVISAGE‐AF trial, patients receiving DOACs presented a higher gastro‐intestinal bleeding rate than those receiving VKAs. However, in these trials, OAC therapy was discontinued before TAVI, and we need more data to understand the possible implications of a U‐OAC strategy. Another aspect to consider, is the indication for OAC in TAVI patients, that might be highly variable. To this regard, in this study atrial fibrillation was the main indication for long‐term OAC and the median CHADSVASc was 5.5, with an estimated thromboembolic risk of 10%/year, that is above the observed bleeding rate. However, though a strategy of uninterrupted OAC has also been recently accepted by an international consensus, this might be not the best choice in patients that need for OAC with a bleeding risk that supersede the ischemic risk, in whom the OAC continuation could be harmful. As already happened in other fields of interventional cardiology (such as pace‐maker implantations and transcatheter ablations), a U‐OAC strategy may simplify and streamline TAVI procedures allowing for an earlier discharge and cost reductions and possibly begin the preferred strategy in some kind of TAVI patients. However, in the absence of randomized data in this setting, the best therapy for every patient, on top of guidelines recommendation, should be tailored on the patient's ischemic/bleeding risk.

CONFLICT OF INTEREST

The authors declare no conflict of interest.